Oregon medical forms for physicians, NPs and PAs

Reporte del Trabajador y del Proveedor Médico para Reclamaciones de Compensación para Trabajadores

Multi-purpose report: first report of injury or disease, aggravation claim, new/omitted condition request, change of attending physician/NP, progress and closing reports, and palliative care requests.

Completed by

Attending physician, nurse practitioner, physician associate, chiropractor or other treating provider (with the worker)

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English and Spanish

Physician's notice of the worker's work status (regular work, modified work with restrictions, or not released) and physical capacities.

Completed by

Attending physician or authorized nurse practitioner

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Provider's notice to the insurer of a proposed elective surgery so the insurer can request a consultation (second opinion).

Completed by

Ordering/surgeon physician

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Records cervical spine range of motion for permanent impairment rating.

Completed by

Closing/impairment exam: attending physician or medical arbiter records measurements under OAR 436-035 standards

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Records lumbar spine range of motion for permanent impairment rating.

Completed by

Closing/impairment exam: attending physician or medical arbiter records measurements under OAR 436-035 standards

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Records thoracic spine range of motion for permanent impairment rating.

Completed by

Closing/impairment exam: attending physician or medical arbiter records measurements under OAR 436-035 standards

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Records elbow, wrist and digit range of motion, sensation loss and amputation for impairment rating.

Completed by

Closing/impairment exam: attending physician or medical arbiter records measurements under OAR 436-035 standards

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Records visual acuity, field deficits, ocular motility, lacrimal and other ocular impairments for rating.

Completed by

Ophthalmologist/optometrist or attending physician performing the closing exam

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Notifies the worker of invasive procedures planned in an independent medical examination and records consent or refusal.

Completed by

Independent medical examiner (physician)

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Insurer's response on whether a consultation exam is scheduled; the physician may use it to notify the insurer, worker and attorney of agreement with the consultation.

Completed by

Insurer (physician completes the agreement portion when used)

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Physician authorizes supplemental disability (wage replacement for secondary jobs) beyond temporary disability for the primary job.

Completed by

Attending physician

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Records lower extremity range of motion for impairment rating.

Completed by

Closing/impairment exam: attending physician or medical arbiter records measurements under OAR 436-035 standards

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Records shoulder range of motion for impairment rating.

Completed by

Closing/impairment exam: attending physician or medical arbiter records measurements under OAR 436-035 standards

Issued by

Oregon Department of Consumer and Business Services, Workers' Compensation Division (WCD)

Format

Fillable PDF

Language

English

Formulario de verificación de condición médica grave

Verifies the claimant's own or a family member's serious health condition, its start date, and the expected length (and frequency, if intermittent) of leave for Paid Leave Oregon medical or family leave.

Completed by

Patient's authorized health care provider per OAR 471-070-1000 (physician, physician associate, NP, nurse-midwife NP, direct-entry midwife, RN, psychologist, regulated social worker, optometrist, dentist, naturopathic physician, chiropractic physician within limits; also spiritual-means practitioners)

Issued by

Oregon Employment Department, Paid Leave Oregon

Format

Fillable PDF

Language

English and Spanish

Certifies the qualifying health condition category (hospital care, incapacity plus treatment, pregnancy/prenatal care, chronic, long-term, multiple treatments, sick child), medical facts, duration and full-time/intermittent leave needed for combined OFLA and federal FMLA leave.

Completed by

Employee's or family member's health care provider

Issued by

Oregon Bureau of Labor and Industries (BOLI)

Format

Word document

Language

English

Certifies OFLA-only leave for pregnancy/prenatal care (incl. fertility treatment) or sick child leave, with the medical facts, duration and leave schedule.

Completed by

Employee's or child's health care provider

Issued by

Oregon Bureau of Labor and Industries (BOLI)

Format

Word document

Language

English

Health care provider certification of a serious health condition for an employer's Unum-insured equivalent plan under Paid Leave Oregon.

Completed by

Health care provider of the employee or family member

Issued by

Unum Group (Unum Life Insurance Company of America)

Format

Fillable PDF

Language

English and Spanish

Formulario de verificación de nacimiento

Certifies the birth or expected birth of the claimant's child for Paid Leave Oregon bonding leave and the extra two weeks of family leave for the birthing parent.

Completed by

Health care provider authorized to certify the birth (obstetric provider, midwife, pediatric provider)

Issued by

Oregon Employment Department, Paid Leave Oregon

Format

PDF

Language

English and Spanish

Certifies an Oregon state employee's or covered family member's health condition category, medical facts, duration and full-time/intermittent/reduced-schedule leave for OFLA/FMLA.

Completed by

Physician or other health care provider of the employee or family member

Issued by

Oregon Department of Administrative Services, Chief Human Resources Office (state employees)

Format

Word document

Language

English

Verifies that the claimant or their child/dependent is a survivor of sexual assault, domestic violence, harassment, bias crimes or stalking for Paid Leave Oregon safe leave.

Completed by

Health care provider or licensed mental health professional/counselor (also law enforcement, attorney, clergy, Title IX coordinator, victim services provider)

Issued by

Oregon Employment Department, Paid Leave Oregon

Format

PDF

Language

English

Vision specialist reports acuity and field results for an applicant who did not pass the DMV vision screening (ORS 807.090).

Completed by

Licensed vision specialist (optometrist or ophthalmologist)

Issued by

Oregon Department of Transportation, Driver and Motor Vehicle Services (DMV)

Format

Fillable PDF

Language

English

Mandatory report by a physician or health care provider of a patient with a severe and uncontrollable cognitive or functional impairment (OAR 735-074) that may make driving unsafe, triggering DMV suspension or evaluation.

Completed by

Mandatory reporters: primary care provider (incl. hospitalists), specialist physician/PA/NP on referral, or health care provider on referral (chiropractor, NP, OT, PT, optometrist, PA, podiatrist, mental health provider)

Issued by

Oregon Department of Transportation, Driver and Motor Vehicle Services (DMV)

Format

Fillable PDF

Language

English

Vision specialist documents low-vision exam results for a driver seeking or keeping a limited vision condition certificate with bioptic telescopic lenses (ORS 807.359-807.369).

Completed by

Licensed vision specialist

Issued by

Oregon Department of Transportation, Driver and Motor Vehicle Services (DMV)

Format

Fillable PDF

Language

English

Health care provider who treats the driver's condition states why the driver cannot operate an ignition interlock device and whether the condition is permanent or temporary, supporting an exemption from a court or DMV IID requirement.

Completed by

Health care provider providing specialized treatment for the condition

Issued by

Oregon Department of Transportation, Driver and Motor Vehicle Services (DMV)

Format

Fillable PDF

Language

English

Healthcare provider certifies the applicant is a 'person with a disability' (ORS 801.387) for a temporary, non-temporary or wheelchair-user parking placard or decal.

Completed by

Licensed physician or healthcare provider (podiatrist, chiropractor, naturopath, nurse practitioner, physician associate, or licensed optometrist)

Issued by

Oregon Department of Transportation, Driver and Motor Vehicle Services (DMV)

Format

Fillable PDF

Language

English

Licensed provider's certification of a permanent or temporary disability (and need for an attendant) so the applicant gets a TriMet Honored Citizen reduced-fare photo Hop card.

Completed by

Certified and/or licensed health care provider (state certification or license number recorded)

Issued by

TriMet (Tri-County Metropolitan Transportation District of Oregon)

Format

PDF

Language

English

Healthcare provider certifies disability for a person (often a child or someone unable to visit DMV) who needs a parking ID card plus a renewable, temporary or wheelchair-user placard.

Completed by

Licensed physician or healthcare provider

Issued by

Oregon Department of Transportation, Driver and Motor Vehicle Services (DMV)

Format

Fillable PDF

Language

English

Physician certifies eligibility of disabled family members for a family disabled person parking permit (ORS 811.609).

Completed by

Licensed physician

Issued by

Oregon Department of Transportation, Driver and Motor Vehicle Services (DMV)

Format

Fillable PDF

Language

English

Coversheet and request form for fee-for-service OHP prior authorization of physical health services, DME, imaging and other services.

Completed by

Requesting provider

Issued by

Oregon Health Authority / Oregon Department of Human Services (Oregon Health Plan fee-for-service)

Format

PDF

Language

English

General fee-for-service OHP prior authorization request for prescription drugs and oral nutritional supplements.

Completed by

Prescriber

Issued by

Oregon Health Authority (Oregon Health Plan fee-for-service pharmacy program)

Format

PDF

Language

English

Speech-language pathologist's evaluation summary that justifies a speech-generating/augmentative communication device for OHP prior authorization.

Completed by

Speech-language pathologist

Issued by

Oregon Health Authority (Oregon Health Plan)

Format

PDF

Language

English

Clinical justification for a standing positioner (stander) requested under OHP fee-for-service DME prior authorization.

Completed by

Treating physical/occupational therapist and prescribing practitioner

Issued by

Oregon Health Authority (Oregon Health Plan)

Format

PDF

Language

English

Uniform form payers must accept for prescription drug prior authorization requests in Oregon.

Completed by

Prescribing provider

Issued by

Oregon Division of Financial Regulation (DCBS)

Format

Fillable PDF

Language

English

Required proof of vaccine education for an Oregon nonmedical (religious, philosophical or other) exemption; signed by a health care provider after counseling, or printed after the online module.

Completed by

Health care provider (physician, NP, PA, naturopath, RN or other practitioner) who discusses vaccines with the parent; or self-printed from the online module

Issued by

Oregon Health Authority, Public Health Division, Immunization Program

Format

PDF

Language

English

Physician-signed medical exemption for ACIP-recognized contraindications, approved by the local public health authority, for Oregon school and child care immunization requirements.

Completed by

Physician (MD/DO)

Issued by

Oregon Health Authority, Public Health Division, Immunization Program

Format

PDF

Language

English

Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.

Completed by

State-licensed healthcare professional (physician, PA, APRN) or registered dietitian

Issued by

Oregon Department of Education, Child Nutrition Programs

Format

PDF

Language

English and Spanish

Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.

Completed by

Licensed health care provider with prescriptive authority (MD, DO, NP, PA)

Issued by

Oregon Health Authority, Public Health Division, WIC Program

Format

Fillable PDF

Language

English

Portable medical order for CPR, treatment intensity and nutrition for people with serious illness or frailty; signed forms are submitted to the Oregon POLST Registry.

Completed by

MD, DO, NP, PA or ND with the patient or representative

Issued by

Oregon POLST Program (OHSU) / Oregon POLST Registry, Oregon Health Authority

Format

Sent for each case

Language

English

Reports the circumstances of death (ingestion of DWDA medication or other cause), complications and end-of-life care of a patient who received a DWDA prescription.

Completed by

Attending (prescribing) physician

Issued by

Oregon Health Authority, Center for Health Statistics

Format

Fillable PDF

Language

English

Documents the attending physician's compliance with each step of the Oregon Death with Dignity Act (terminal diagnosis, capability, oral and written requests, consultations) when a lethal-dose prescription is written.

Completed by

Attending physician

Issued by

Oregon Health Authority, Center for Health Statistics

Format

Fillable PDF

Language

English

Consulting physician confirms the terminal diagnosis, prognosis, capability and voluntariness of a patient requesting medication under the Death with Dignity Act.

Completed by

Consulting physician

Issued by

Oregon Health Authority, Center for Health Statistics

Format

Fillable PDF

Language

English

Psychiatrist or psychologist reports whether a Death with Dignity patient has a psychiatric or psychological disorder or depression causing impaired judgment.

Completed by

Psychiatrist or licensed psychologist (when referral is required)

Issued by

Oregon Health Authority, Center for Health Statistics

Format

Fillable PDF

Language

English

Attending provider attests that the patient has a debilitating medical condition and that marijuana may mitigate its symptoms, supporting an OMMP registry card application or renewal.

Completed by

Oregon attending provider with primary responsibility for the patient: MD/DO, physician associate, nurse practitioner, clinical nurse specialist, CRNA or naturopathic physician

Issued by

Oregon Health Authority, Oregon Medical Marijuana Program (OMMP)

Format

PDF

Language

English

Clinician report of a confirmed or suspected reportable disease or condition (OAR 333-018) to the patient's local health department.

Completed by

Clinician who diagnoses or suspects the condition

Issued by

Oregon Health Authority, Public Health Division

Format

Fillable PDF

Language

English

Licensed physician, NP or PA certifies a diagnosed condition, the electrical equipment/services needed, and how losing power would endanger the patient (OAR 860-021-0410), for PGE's medical certificate program and payment flexibility.

Completed by

Licensed physician, nurse practitioner or physician assistant

Issued by

Portland General Electric (PGE)

Format

Fillable PDF

Language

Bilingual

Medical practitioner certification that the applicant meets a permanent disability criterion (mobility aid, lung disease, cardiac class III/IV, cannot hold firearm/bow/rod, 20/200 vision) for an ODFW Disabilities Permit (e.g. hunting from a vehicle, designated hunter/angler).

Completed by

Licensed physician, licensed physician assistant or certified nurse practitioner

Issued by

Oregon Department of Fish and Wildlife (ODFW), License Services

Format

PDF

Language

English